Hospital Reimbursement for Carotid Stenting and Carotid Endarterectomy

Abstract

rent critical limb ischemia, loss of secondary patency, and major amputation in those with primary occlusion were 55%, 79%, and 22%, respectively, compared with 18%, 10%, and 10% for the remaining cohort (P Ͻ .001). On univariate analysis (hazard ratio [HR] [95% confidence interval]), African American race (1.4 [1.01-1.9]), use of anticoagulants (1.54 [1.2-2]), use of alternative/spliced vein conduit (1.44 [1.1-1.97]) and graft diameter Ͻ3 mm (1.97 [1.2-3.3]) were associated with increased risk of primary occlusion. On multivariate analysis (HR [95% confidence interval]) graft diameter Ͻ3 mm (1.8 [1.1-3]) and use of anticoagulants (1.4 [1.04-1.89]) were independent predictors. In 110 individuals, DUS had revealed no critical threshold abnormalities prior to the thrombosis. On multivariate analysis, graft diameter Ͻ3 mm (2.3 [1.2-4.7]) was the sole independent predictor of these unheralded occlusions.Conclusions: Approximately one-third of primary vein graft events are occlusions even in the setting of DUS surveillance. Smaller diameter grafts are at increased risk. These findings suggest that prevention of vein graft thrombosis requires further improvements in risk stratification, surveillance, and antithrombotic therapies.

Commentary: Carotid Artery Stenting: Still Not as Cost-Effective as Carotid Endarterectomy, but the Contest Continues

“…The cost-effectiveness analysis of CAS vs. CEA by Donovan et al 1 reaches the same conclusion as most similar cost-effectiveness analyses published to date, i.e., that CAS is associated with considerably higher costs compared with CEA. 2–9 The main reason for the difference in cost between CAS and CEA is the charges directly associated with the procedure, namely, the expensive endovascular equipment and instruments.…”

“…At present, CAS is more costly and less cost-effective than CEA, 1 but it seems that the economic gap between the two procedures is now narrower than what it was a few years ago. 7 With better patient selection, 8,16 centralization of CAS procedures, 14,15 and improvements in CAS equipment and expertise, the cost-effectiveness of CAS is expected to improve.…”

“…After comparing the cost-effectiveness of carotid artery stenting (CAS) vs. carotid endarterectomy (CEA), Donovan et al 1 in this issue of the JEVT concluded that CAS is more costly than CEA and cannot be considered cost-effective for most carotid patients. Although hospital reimbursement was 16% higher for CAS compared with CEA ($12,000±$7372 vs. $10,160±$6840, respectively; p=0.02), the net income per procedure for the hospital was 29% lower for CAS vs. CEA ($2603 vs. $3487, respectively).…”

“…Although hospital reimbursement was 16% higher for CAS compared with CEA ($12,000±$7372 vs. $10,160±$6840, respectively; p=0.02), the net income per procedure for the hospital was 29% lower for CAS vs. CEA ($2603 vs. $3487, respectively). 1 The reason for this was the almost 50% higher cost of CAS material ($9396 vs. $6673 for CEA). 1…”

“…10 Based on this recommendation, 10 we previously demonstrated that if the percentages of CEA and CAS procedures performed during these 3 years had been the same (i.e., 50% CAS and 50% CEA), this would translate into an additional cost of ∼$2,000,000,000. 11 However, based on the cost-effectiveness analysis performed by Donovan et al, 1 it appears that the difference in cost between CAS and CEA has decreased since the 2011 cost-effectiveness analysis 7 and will hopefully decrease even more in the future.…”